Suprachoroidal Implants (SOLX®, STARflo™, iStent Supra®, CyPass®)

Suprachoroidal Implants [SOLX®, STARflo™, iStent Supra®, CyPass®]. Part 10 of 12 of “What’s New In Glaucoma Surgery” Presentation, a continuing education course for Optometrists presented by Patient-Focused Ophthalmologist, Dr. David Richardson on May 20, 2015.

Suprachoroidal Implants: A Quick Review

SOLX® Gold Micro Shunt

One of the earliest Suprachoroidal Implants is what’s called the SOLX® Gold Micro Shunt and in theory it made a lot of sense. You take these two thin gold plates and you sandwich them together with little channels in between them and the idea was that the body shouldn’t really react to gold (it’s pretty inert). And you would place the shunt right here in the angle, in the Suprachoroidal space and fluid would come in from here and then out these little pores, you see these little channels here and it would allow fluid to just flow out. And in theory, because the body doesn’t react to gold as much as it does to other types of metals, it shouldn’t scar down and you shouldn’t get fibrotic tissue plugging up these channels. Well just as the theory of Argon Laser Trabeculoplasty and Dr. Cairns original desire for Trabeculectomy didn’t quite pan out, neither has this panned out. That the gold shunt has really been unimpressive. Only a modest IOP lowering, medication-reducing, at best. You might get some patients off a medication but it’s unlikely the going to get a big pressure-reduction benefits. Seem to be time-limited, so eventually it does – this channel seemed to, get plugged up. Once they get plugged up, you lose the effect. There’s a very high rate of failure. They’ve actually had some that have been explanted. They’ve gone back in, taken them out, taken a look at them under a microscope and seeing that, “yeah, we may value gold but the body doesn’t seem to really value it as much as we do.” What else can we do?

STARflo™ Glaucoma Implant

Well… there’s a company that has created a silicon material instead of using gold they use silicon you might say, “Well silicon isn’t that somewhat pro-inflammatory?” Well certain types of silicon can be– but this particular silicon biomaterial, they’ve created these tiny little micropores in it and let me show you the procedure a bit involved here. It remains to be seen whether this is going to become really popular because all the focus in glaucoma at this point seems to be how fast can I do it, can I do it without creating the sclera incision. But what you see here is this, also, is going to make most surgeons kind of queasy because you see, what’s happening here — you got this flap and now his free-handing in it, right into the Suprachoroidal space. So, it’s cut down to the choroid and at least for now as a resident if we ever saw Choroid our heart stop, right? And he just stuck this device into the choroid, creating a potential space, which again I see Choroid a fair amount doing Canaloplasty, this would make a little bit nervous. Now, he’s going to gently, delicately pass the STARflo™ implant between the sclera and the Suprachoroidal space Now the keratome has just been used to create an incision underneath the superficial flap into the anterior chamber and what’s going to be done is this tag here is going to be placed in the anterior chamber and then the flap will be placed back down. So, this STARflo™ device with these micropores will allow fluid to flow from the anterior chamber through these micropores into this Suprachoroidal space here. It’s a pretty neat idea but again the question is even if it works is this something that’s going to take off? Because I’m going to show you lots things that I think are really neat.

Glaukos iStent Supra®

This here’s the iStent Supra®. It’s not yet available in the US and I may not be a fan of the iStent that I showed you earlier as far as the Trabecular Microbypass. But, I’m really excited about the iStent Supra® and another one that I’ll show you called the CyPass® Suprachoroidal Implant. Because these are just sample, elegant, fast and they seem to work. So the iStent Supra® is basically a small tube– the special material here that would go into the Suprachoroidal space with a titanium collar here. And so far, the initial studies have been impressive when these have been implanted either alone or the time a cataract surgery, at 12 months, one study showed a pressure reduction of 20%. That’s pretty good. Another study, at 18 months, showed an almost 50% reduction in pressure. Somewhere between 20 – 50 percent I’ll take that. Now, here you are going to see why this compared to the STARflo™ is so exciting. What we see here — this is Dr. Jose Belda, is a Gonioscopic view and he’s inserting it right now. Right now, into the angle there. Little device and there it is, bam! You could see the collar sticking out. That’s titanium collar. The rest of it is in the Suprachoroidal space. So, whereas the STARflo™ require cutting down now, putting something down, *** it along a Suprachoroidal space. On the iStent Supra® just inject it, into that space. So, this is a really a very elegant device.

CyPass® Micro-Stent – Transcend Medical

There’s also a competing device and it’s called the CyPass® Micro-Stent. It’s also a tube. This tube has little micro holes in it but it’s the same idea, you can see here’s the angle. There’s the iris and you just shove it into the Suprachoroidal space. I mean, it’s really– it’s maybe elegant but what you doing is shoving it and Suprachoroidal space. It’s not as easy as it sounds. It’s a small space. Then the other remaining devices are…